Antibacterial preparations also used systemically
Fusidic acid is a narrow-spectrum antibacterial used for
staphylococcal infections. Fusidic acid has a role in the
treatment of impetigo.
An ointment containing fusidic acid is used in thefissures
of angular cheilitis when associated with staphylococcal
infection. See Oropharyngeal fungal infections p. 709 for
further information on angular cheilitis.
Metronidazole is used topically to treat rosacea and to
reduce the odour associated with anaerobic infections; oral
metronidazole is used to treat wounds infected with
anaerobic bacteria.
Antifungal preparations for the skin
Most localised fungal infections are treated with topical
preparations. To prevent relapse, local antifungal treatment
should be continued for 1 – 2 weeks after the disappearance
of all signs of infection. Systemic therapy is necessary for
scalp infection or if the skin infection is widespread,
disseminated or intractable; although topical therapy may be
used to treat some nail infections, systemic therapy is more
effective. Specimens of scale, nail or hair should be sent for
mycological examination before starting treatment, unless
the diagnosis is certain.
Dermatophytoses
Ringworm infection can affect the scalp (tinea capitis), body
(tinea corporis), groin (tinea cruris), hand (tinea manuum),
foot (tinea pedis, athlete’s foot), or nail (tinea unguium,
onychomycosis). Tinea capitis is a common childhood
infection that requires systemic treatment with an oral
antifungal; additional application of a topical antifungal,
during the early stages of treatment, may reduce the risk of
transmission. A topical antifungal can also be used to treat
asymptomatic carriers of scalp ringworm.
Tinea corporis and tinea pedis infections in children
respond to treatment with a topicalimidazole(clotrimazole
p. 724 , econazole nitrate p. 725 , or miconazole p. 725 )or
terbinafine cream p. 726. Nystatin p. 710 is less effective
against tinea.
Compound benzoic acid ointment(Whitfield’s
ointment) has been used for ringworm infections but it is
cosmetically less acceptable than proprietary preparations.
Antifungal dusting powders are of little therapeutic value in
the treatment of fungal skin infections and may cause skin
irritation; they may have some role in preventing re-
infection.
Antifungal treatment may not be necessary in
asymptomatic children with tinea infection of the nails. If
treatment is necessary, a systemic antifungal is more
effective than topical therapy. However, topical application
of tioconazole p. 726 may be useful for treating early
onychomycosis when involvement is limited to mild distal
disease, or for superficial white onychomycosis, or where
there are contra-indications to systemic therapy. Chronic
paronychia on thefingers (usually due to a candidal
infection) should be treated with topical clotrimazole or
nystatin, but these preparations should be used with caution
in children who suck theirfingers. Chronic paronychia of the
toes (usually due to dermatophyte infection) can be treated
with topical terbinafine.
Pityriasis versicolor
Pityriasis (tinea) versicolor can be treated with ketoconazole
shampoo p. 725 orselenium sulfideshampoo. Topical
imidazole antifungals such as clotrimazole, econazole
nitrateand miconazole or topical terbinafine are alternatives,
but large quantities may be required.
If topical therapy fails, or if the infection is widespread,
pityriasis versicolor is treated systemically with an azole
antifungal. Relapse is common, especially in the
immunocompromised.
Candidiasis
Candidal skin infections can be treated with topical
imidazole antifungals clotrimazole p. 724 , econazole nitrate
p.^725 , or miconazole p.^725 ; topical terbinafine p.^726 is an
alternative. Topical application of nystatin p. 710 is also
effective for candidiasis but it is ineffective against
dermatophytosis. Refractory candidiasis requires systemic
treatment generally with a triazole such asfluconazole
p. 374 ; systemic treatment with griseofulvin p. 379 or
terbinafine isnot appropriatefor refractory candidiasis. See
the treatment of oral candiasis and for the management of
nappy rash.Angular cheilitis
Miconazole cream is used in thefissures of angular cheilitis
when associated withCandida.
Compound topical preparations
Combination of an imidazole and a mild corticosteroid (such
as hydrocortisone 1 %p. 739 ) may be of value in the
treatment of eczematous intertrigo and, in thefirst few days
only, of a severely inflamed patch of ringworm. Combination
of a mild corticosteroid with either an imidazole or nystatin
may be of use in the treatment ofintertriginous eczema
associated with candida.Antiviral preparations for the skin
Aciclovir cream p. 729 is used for the treatment of initial and
recurrent labial, cutaneous, and genitalherpes simplex
infectionsin children; treatment should begin as early as
possible. Systemic treatment is necessary for buccal or
vaginal infections or if cold sores recur frequently.
Herpes labialis
Aciclovir cream can be used for the treatment of initial and
recurrent labial herpes simplex infections (cold sores). It is
best applied at the earliest possible stage, usually when
prodromal changes of sensation are felt in the lip and before
vesicles appear.
Penciclovir cream is also licensed for the treatment of
herpes labialis; it needs to be applied more frequently than
aciclovir cream.Parasiticidal preparations for the skin
Suitable quantities of parasiticidal preparationsArea of body Skin creams Lotions Cream rinses
Scalp (head lice) 50 – 100 mL 50 – 100 mL
Body (scabies) 30 – 60 g 100 mL
Body (crab lice) 30 – 60 g 100 mL
These amounts are usually suitable for a child 12 – 17 years for
single application.Scabies
Permethrin p. 729 is used for the treatment ofscabies
(Sarcoptes scabiei); malathion p. 729 can be used if
permethrin is inappropriate.
Benzyl benzoate is an irritant and should be avoided in
children; it is less effective than malathion and permethrin.
Ivermectin p. 383 (available from‘special-order’
manufacturers or specialist importing companies) by mouth
has been used, in combination with topical drugs, for the
treatment of hyperkeratotic (crusted or‘Norwegian’) scabies
that does not respond to topical treatment alone.
Application
Although acaricides have traditionally been applied after a
hot bath, this isnotnecessary and there is even evidence
that a hot bath may increase absorption into the blood,
removing them from their site of action on the skin.
All members of the affected household should be treated
simultaneously. Treatment should be applied to the wholeBNFC 2018 – 2019 Infections of the skin 721
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